As experienced voices are often identified as being associated with specific individuals (e.g., Nayani & David, 1996), voice-experiences often imply a relational moment. These relational aspects of AVHs have been used in a range of psychological studies.
For example, Bell (2013) – without going into greater detail – proposes that AVHs may be due to abnormal internalisation of other people‘s voices. He assumes that a voice- hearing experience is constituted by misidentified imagined voices rather than misattributed thoughts. He conceptualises AVHs as primarily social and embedded in the voice-hearer‘s social world, which in turn is assumed to influence a voice‘s appearance. More specifically, he proposes that voices commonly act as ―internal models of social actors‖ (Bell, 2013, p.2).
In fact, results of a range of questionnaire studies indicate that patterns of relationships to voices are closely linked to relationship patterns that individuals who experience them have in their shared social lives.
Studies included in the present review have focused on the following relationship aspects: power (Birchwood et al., 2004, 2000; Hayward, 2003), social rank (Birchwood et al., 2004, 2000), and proximity (Hayward, 2003). All participants in those studies had a schizophrenia or related diagnosis.
The overall picture provided by the reviewed studies is that voices are experienced as powerful. In Birchwood et al.‘s studies (2000, 2004) voice-hearers in general reported experiencing their dominant voices as being more powerful than themselves. Applying a different measure of power, Hayward (2003) obtained somewhat contradictory results: voice- hearers who related to their dominant voice from ―below‖ tended to experience more benevolent voices with less negative content, to relate with their voices from a position of closeness and to engage with their voices.
This difference might be due to the use of different ―power‖ measures as well as due to different samples: a more powerful voice may have very different effects depending on the voice‘s content and the voice being perceived as malevolent or benevolent. It might be that in Birchwood et al.‘s (2000, 2004) samples powerful voices were experienced as rather persecutory and malevolent, and in Hayward‘s (2003) sample as rather benevolent supernatural powers, and thus participants related differently to powerful voices, for example.
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In terms of coping strategies, voice-hearers that reported to experience their dominant voice as powerful and malevolent tended to ―resist‖ to their voices, that is, refuse to do what they say, whereas individuals describing their dominant voice as benevolent voices tended to engage with them, for example, try to make contact with their voices (Birchwood & al., 2004).
Table 7
Overview over the reviewed studies focusing on relational aspects of AVHs. Authors
(year)
Participants Type of study Main results/thesis
Bell (2013) - Theoretical - voice-hearing experiences as primarily social and embedded in the voice-hearer‘s social world,
- voices commonly act as ―internal models of social actors‖ (Bell, 2013, p.2) Birchwood et al. (2000) Birchwood et al. (2004) N = 59 schizophrenia or schizo-affective disorder patients with AVHs
(ICD-10) (all except one: neuroleptic medication)
N = 125 schizophrenia patients with AVHs (ICD-10)
(over 98% on neuroleptic medication)
Questionnaire
measures of power and social rank difference between voice & voice-hearer + social relationships
- dominant voices experienced as being more powerful than voice-hearers
- perception of powerlessness linked to degree of depression - patterns of relationships to voices linked to relationship patterns with significant others
- reported voice frequency and volume higher, when high power and higher social rank ascribed to the dominant voice
Hayward (2003)
N = 26 schizophrenia patients with AVHs, N = 1 manic depressive psychosis patient with AVHs (all: on antipsychotic medication)
Semi-structured interview: based (amongst others) on You to Voice (YTV); individuals relating to others questionnaire; revised beliefs about voices questionnaire
- VH as ―relating to an interpersonal other‖ (p.369)
- relating to voices from a dominant position associated with a low voice frequency
- relating to dominant voice from ―below‖ associated with experiencing more benevolent voices with less negative content
as well as relating with the voice from a position of closeness and engage with it
The ―power relationship‖ between voice-hearer and voice was predicted by the perceived ―power relationship‖ to significant others in the voice-hearer‘s life (Birchwood et al., 2000; Hayward, 2003). That led Birchwood et al. (2004) to conceptualise the experiences of voice-hearers with their dominant voice as a mirror of their general social relationships in which they use to feel subordinate. However, there is reason to assume that not all aspects of relationship patterns with significant others can be generalised to the relationships with voices. Some relationship features seem to be unique to relationships to voices: Hayward
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(2003) reports that voice-hearers generally related to their predominant voice in a distant manner, which was not true of their relationship to significant others.
Taken together, in the just reviewed studies we find a shift away from the focus on audibility towards voice-hearing‘s social aspects. In the context of these studies AVHs are not simply conceptualised as auditory experiences without corresponding stimuli, but as ―constructed as that of relating to an interpersonal other‖ (Hayward, 2003, p.369).
There is evidence, that the voice-hearing experience may be shaped by social patterns occurring in a person‘s life and that voice-hearers employ similar interaction patterns when they relate to their voices and significant others in their lives.
The just reviewed studies are based on the assumption that beliefs about voices are a crucial factor in how a voice is experienced. However, it can be questioned if the concept of belief is the right concept for describing voice-hearer‘s experiences of a voice‘s power or proximity. Put differently, we may ask: is it a matter of belief if a voice-hearer experiences his/her voices as malevolent, powerful, and so on.